Ask the Expert: Serious Injury and Fatality Prevention through Safety Culture Improvement

Serious Injury and Fatality Prevention

In a recent webinar, Cority’s Sean Baldry, CRSP, explored how slight changes to the way businesses approach safety culture can have dramatic results when it comes to serious injury and fatality (SIF) prevention. Sean provides answers below to some of the great questions from audience members that we didn’t get a chance to cover during the session. Read on to learn more about how your organization can reduce SIFs by shifting the way it looks at building and sustaining safety culture.

What questions should be asked of every workplace incident to determine if Serious Injury and Fatality potential exists?

There’s no single, standardized approach to identifying serious injury and fatality potential. It’s best to start with defining what “serious injury” means for your organization. In a way, how your business defines what it sees as serious will help it narrow down the things it needs to look for to determine serious injury and fatality potential.

In most cases, serious injury and fatality potential is determined by identifying the presence of SIF precursors within an event. By defining what your organization sees as a SIF precursor will again help it narrow down those SIF potential events from all others for deeper examination.

So, if I define a serious injury and fatality precursor as an event involving a high-risk task where the absence of critical control measures significantly increases the risk of a SIF, the questions I might ask to help identify serious injury and fatality potential may include:

  • Did the task involve a critical hazard or permit-required work? 
  • Were the critical life-saving measures required for this task in place? 
  • If these measures were in place, were they effective and/or followed?

Alternatively, your organization may decide to take a more objective, quantitative approach through the use of calculated risk scores that consider variables including event probability and consequence. Risk scores that exceed a pre-set risk threshold would automatically be considered “Serious Injury and Fatality potential” events, which would be referred for more in-depth investigation and analysis. It’s important to remember that such quantitative methods would need to be regularly validated to ensure that some events are not unnecessarily “promoted” to serious injury and fatality status, or that genuinely serious events are not underscored as a means to prevent further scrutiny.

Overall, the value of any process to identify SIF potential will hinge heavily on the degree of training and education provided to the workforce. For any SIF prevention program to work, the entire workforce needs to be well versed on the purpose and intent of the program, what SIFs and SIF precursors are, how to assess SIF potential, and the overall goals the organization seeks to achieve.

Learning teams were introduced as an effective means to understand issues in system design that can make human error more likely to occur. What does a learning team consist of and how does it work?

During the webinar, we highlighted the need for organizations to become more comfortable exploring, discussing and learning from their failures. We also noted that while workers are often closest to the hazard – at the proverbial “sharp end of the stick” – they are often excluded from conversations on how processes should be designed and improved despite having arguably the best understanding of those processes, what things work well, and what things don’t.

A learning team is really a function of the cultural shift needed to become more open about our failures. It’s not intended to be a heavily-structured, formal committee that represents the workplace on all investigative matters.  Instead, learning teams function as a tool to help the organization quickly get an understanding not of why an event happened, or who caused it, but how the failure occurred.

As we covered in the webinar, studies have shown that most incidents are influenced by unintentional errors triggering latent conditions within a system. And the way systems are designed often create “error-traps” – conditions that make the chances of a worker making a non-recoverable error more likely. 

Learning teams are intended to allow the business to assemble a group of workers together at a moment’s notice to explore a failure in more detail, understand how the error happened, and recommend system changes to reduce the potential of a similar failure. Workers included in the learning team may change depending on the work and the nature of the failure. But a key feature is that the workers that actually do the job need to be heavily involved in this process since they have in-depth knowledge that needs to be leveraged to find improvements and promote learning.

Learning teams are a great way to help shift the organization from what human performance expert, Dr. Todd Conklin, calls a “name and blame” approach to a “diagnose and treat” approach to safety management 1.  Understanding how errors happen starts with learning from our failures, and acknowledging that fixing the worker will not necessarily fix the problem in all cases.

READ MORE: Reduce Serious Injuries and Fatalities by Improving Safety Culture

Small companies don’t create much risk data each year.  They may have few SIFs from day-to-day. How can they benefit from data in the same way as larger organizations to prevent serious incidents?

Interestingly, I don’t think this issue is limited to small businesses. Naturally, as organizations get better at reducing incidents in the workplaces, the amount of available data, at least from a lagging indicator perspective, starts to decrease. This represents a bit of a performance paradox – essentially as the organization improves it has less access to the information it needs to continue improving. And that means the business needs to shift.

I think this points to a clear limitation with using lagging indicators to measure safety performance. But it also indicates why a shift toward more leading indicators is so vital as your safety culture matures and performance improves. As leading measures are forward-looking, they remain available to the organization to help it continuously gauge whether it is engaging in the activities necessary to identify and mitigate serious injury and fatality precursors that will enable it to prevent future SIFs. Organizations also need to recognize that as the culture changes, so must our leading indicators.

But starting with a few simple indicators can really help businesses of any size collect the data needed to assess performance and make the required adjustments to prevent harm and promote improvement.

Some leading indicators include:

  • Number of near miss incidents reported
  • Number of incidents with SIF potential identified
  • Days to close corrective actions
  • Number of proactive inspections completed

There are way more leading indicators than what’s mentioned here. The important point is to find indicators that support your high-level goals, and which can be easily measured and communicated throughout the organization.

RELATED: Leverage Organizational Data to Measure and Improve Your Safety Culture and Performance

Can culture change be measured through language, such as the type of conversations that take place within an organization?

I think it’s crucial that we return to the idea of culture for a quick second.

Safety culture is the product of 3 interrelated aspects: 

  • a situational aspect consisting of the organization’s policies, procedures and systems
  • a behavioral aspect that focuses on how people within the business behave with respect to safety
  • a psychological aspect that concerns how we feel about safety, specifically our attitudes, perceptions and values

It’s important to note that the way in which we speak to each other in an organization, and the language we use when we talk about safety, will have an influence on the values and attitudes we develop toward safety that will in turn impact our behavior. So, while I cannot say with certainty that we can measure safety culture change through language, we need to recognize that the language we use really matters. The language we use to engage people in safety will influence the way they do things.

Renowned safety expert Dr. Andrew Sharman addresses language and safety culture in this way:

If we can find a way to talk about safety constructively, in functional terms, we really underline what we mean. A question often posed by leaders to their workers is ‘How quickly can you get that job done?’ By adding just one word to this sentence – quickly – we can completely change the response we’d like to encourage in others.” 2 

We need to be mindful that the words we use and how they are interpreted will change the perception of what the organization considers most important.

According to Dr. Sharman, there are 3 specific words we should keep in mind when speaking about safety:

  1. Why – This word can be particularly powerful in helping our colleagues understand the value and intent of what we’re asking them to do. ‘Why’ also allows leaders to show interest in the work of others and expresses a curiosity to learn. We’ve seen that in most cases where an incident occurs, it results from a worker with good intentions making an honest mistake. Asking ‘why’ encourages leaders to dive deeper to understand not only what the worker did, but also the context that influenced their decisions that will help identify ways to prevent a similar occurrence in the future.
  • But There should be a big warning sign attached to this word. Keep in mind that when you insert ‘but’ into a conversation, there’s a good chance that the person you’re talking to will forget all about what you said before the ‘but’, and only focus on what followed it. So, while you might say, “We need to do this job safely, but it must be done by 5 o’clock”, what your workers hear is “by 5 o’clock”.
  • Imagine – One of the problems with trying to encourage safety improvement is that in most cases, work is performed safely so workers don’t have the value of negative experience to learn from. For some people, then, it’s difficult to think of themselves as impacted by a work-related injury or illness that seems somewhat abstract. ‘Imagine’ opens their minds and helps them visualize a possible future. It may cause them to re-think what they do before they do it, or explore the context of their actions to help identify ways to improve systems and/or behaviors.

To learn more about the power of language and other ways to influence safety culture change, check out the IOSH-certified Behavioral Safety Leadership course.

Some companies create performance incentives to motivate employees to achieve safety goals, like an incident frequency rate target. How is this allowed?  Would incentives not simply discourage safety reporting?

Incentives present an interesting double-edge sword: while they’re designed to motivate people toward achieving important goals, they may, if poorly thought out, reinforce specific behaviors that could ultimately undermine your safety culture efforts, like under-reporting or falsifying data. So whenever considering incentives linked to safety performance, we need to be mindful of exactly what we’re looking for, and whether the process to arrive at the goal is as important as the goal itself.

Start by considering what you’re ultimately looking to achieve: How is this goal going to assist your organization build a more robust, more open and more sustainable safety culture? How is it going to prevent a serious injury and fatality? 

Next, explore not only the behaviors necessary to achieve that goal, but also those unintended behaviors that could arise and undermine safety culture in the pursuit of those goals. The desire to under-report safety incidents – essentially push events under the rug in order to “meet the numbers” – will eliminate great opportunities to explore failures more deeply, make our processes more resilient and reduce the risk a serious injury and fatality. We therefore need to consider these items carefully. 

Finally, think about what measures will be used to monitor progress and evaluate success. Think about measures that are actionable and encourage forward-looking accountability. Select goals that employees need to do something proactively to influence, and so they can be pushed to achieve, instead of goals based on things that already have happened and therefore can’t be directly influenced. This is where leading indicators come in.

The truth is that incentives programs are permitted under OSHA. While OSHA views incentive programs as “an important tool to promote workplace safety and health”, it acknowledges that interested employers need to design incentives in such a way that it will not discourage reporting.

But let’s be clear: just because you can incentivize safety performance doesn’t mean you should. Building a strong safety culture in which all workers are actively engaged and feel they have the opportunity to contribute to building a safe and healthy workplace will create an atmosphere in which people will want to work together toward safety goals, whether or not incentives exist.

Learn More About Safety Culture

To learn more about how to measure safety performance, prevent a serious injury and fatality, and drive your safety culture forward, check out this eBook from our in-house health and safety experts:


1 Conklin, Todd. Pre-Accident Investigations: An introduction to Organizational Safety. New York: CRC Press, 2012. 134 pp.

2 Sharman, Andrew.  From Accidents to Zero: A practical guide to improving your workplace safety culture. London: Maverick Eagle Press, 2014.  144 pp.